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Ombudsman hits CASA over inaction on Coroner’s Courts

Ombudsman hits CASA over inaction on Coroner’s Courts

Over the past three years, there has been a continuing pressure on the way CASA interacts with the Coroners Courts.

This pressure goes from just plain avoidance by the regulator to abject refusal to deal with the Coronial outcomes and deal with the safety matters arising from the relevant inquest.

That the Lockhart River tragedy, in the terms of the families involved, was “..influenced…” by the use of Ian Harvey as Counsel assisting the Coroner, needs a distinct reminder to the Ombudsman as to how a negative influence can be made by the regulator.

For those who do not know who Ian Harvey is – Ian Harvey is the preferred barrister for CASA. When the heat comes on CASA legal, Ian Harvey is not far away.

That he earned over $1.39m in the period 2002 to 2012, not including the amounts paid while “…assisting the coroner…”, from CASA alone must give some concern of Harvey’s independence. In a previous post on this site, there was an upgrade of the numbers below in 2013.

In 2006, the Senate was asking serious questions through Senator McLucas about the connections and payments of CASA legal, in particular to Ian Harvey.

Even in the Hemple affair in Brisbane, which bears some chilling similarities to the PelAir ditching and the failures by both ATSB and CASA in the matters, Ian Harvey pops up again.

casa - harvey

In 2013, an aviation investigative group reported to the Australian Senate committee about issues surrounding CASA, ATSB and the Coroner Court’s system:


The intent was to present alternative or revised assessment of accidents where, in the opinion of the group, the most probable and ranked contributing causes related to the incidents were not clearly defined or presented for Coronial considerations…………”

In conclusion, the report said:

  1. We believe that none of the promised legislation, against which many Coroners based their recommendations, is available for practical use.
  2. We believe none of the Coroners recommendations have been adopted to produce, in any practical, meaningful way improved safety outcomes.
  3. We believe that, in real terms, there has been no pro active approach [by CASA] to reduce the self evident risks or casual factors related to the provided reports.
  4. We firmly believe that all the presented incidents still have the potential to be repeated.

The Ombudsman’s report does go some way towards achieving these ends, but depends on the integrity [I believe this is compromised] of CASA and ATSB. The re-examination of the PelAir matter will clearly demonstrate whether CASA and the ATSB have “…got the message…”


The OMBUDSMAN’s Report:

EXECUTIVE SUMMARY [Ombudsman report – April 2015]

Between 2009 and 2013 (the period considered in this report), 153 people died in 120 accidents involving general aviation aircraft. Many of these deaths were the subject of coronial inquests, which perform an important function in publicly examining the causes of such accidents, and what can be done to minimise the risk of similar accidents and deaths in the future. As result of such inquiries, coroners regularly make findings and recommendations addressed to the Civil Aviation Safety Authority, which has primary responsibility for the maintenance, enhancement and promotion of the safety of civil aviation in Australia.

This investigation looked at how CASA considers, responds to, and implements coronial recommendations, including its internal records for tracking decisions and progress against the recommendations. We considered the reasonableness of CASA’s general arrangements for handling coronial recommendations, and the specific actions it has taken in response to each of the coronial inquests within the scope of this investigation. However, given the high level of technical detail and expertise involved in aviation matters, we did not seek to form a view on the soundness of CASA’s acceptance or refusal of any particular finding or recommendation.

Our investigation identified opportunities for improvement in relation to a range of matters, including:

  • CASA’s awareness of coronial inquiries and recommendations
  • CASA’s approach to assessing coronial recommendations, particularly those suggesting increased enforcement of existing regulations, or the introduction of new regulations
  • CASA reporting publicly both on its assessment of coronial recommendations, and its progress in implementing those recommendations it has accepted, and
  • CASA’s capacity to ensure that Recreational Aviation Administration Organisations (RAAOs) implement recommendations that are relevant to their membership.

We made eight recommendations to CASA, focusing particularly on the transparency of CASA’s assessment of coronial recommendations, and its public accountability for implementing recommendations to which it has agreed.

The recommendations include that CASA:

  • takes steps to improve its working relationships with all State and Territory coroners’ offices, and ensures that a representative attends all coronial inquests into general aviation fatalities
  • responds publicly to all coronial recommendations, clearly explaining its reasons for accepting or refusing each recommendation, and what it has done or will do to implement accepted recommendations
  • reviews its record keeping arrangements for tracking its assessment and implementation of coronial recommendations
  • develops a mechanism by which it can ensure that RAAOs implement coronial recommendations within their respective regulatory responsibility
  • commits to reporting publicly, at least annually, on its progress in implementing coronial recommendations.

Broadly speaking, CASA has accepted all of our recommendations. Its detailed response to each recommendation is incorporated into the body of this the report.


#kharon comments on this matter

The following article in the Australian today [15th April 2015], makes comment over the Ombudsman report into CASA.


Rap on knuckles for CASA over its inaction

A light plane crash near Albany, WA

The aviation watchdog has been chastised for failing to respond to past coronial recommendations. Source: AAP

THE aviation watchdog has been chastised for failing to respond to past coronial recommendations.

COMMONWEALTH Ombudsman Colin Neave says the Civil Aviation Safety Authority needs to lift its game.

Mr Neave made eight recommendations in a report released on Wednesday, including improved links between CASA and state and territory coroners offices, as well as annual reporting on the progress of implementing recommendations. Between 2009-2013, 153 people died in 120 general aviation crashes.




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